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Beyond shyness: Overcoming the fear of social situations

Everyone feels nervous from time to time. Going on a first date or giving a speech often causes that butterflies-in-your-stomach feeling. Or you may initially feel shy at a party among a group of strangers, but then warm up to them.

For some people, though, this sort of normal nervousness is magnified into extreme fear and anxiety. They avoid dating, giving speeches or attending parties altogether. They fear being watched or humiliated while doing something in front of others. Everyday social activities, even the most mundane, may become virtually impossible. You may not even be able to eat with others or sign a personal check in public.

When social anxieties become this extreme and disrupt your life, interfere with education or work, and lead you to avoid certain situations, they may have crossed the line into a condition known as social phobia.

"Social phobia can severely limit dating, academic achievement and career choice," notes Lois Krahn, M.D., a psychiatrist at Mayo Clinic in Scottsdale, Ariz. "It can disrupt much of life's activity."

But the right treatment — counseling, behavioral techniques and medication — can improve the quality of life and open up opportunities that the fear and anxiety had shut out.

Social phobia, sometimes called social anxiety disorder, isn't the same as shyness or so-called stage fright. In fact, sometimes it's perfectly reasonable to have some fear in certain social situations.

If you're afraid of being called on in class or at a meeting because you haven't prepared, that's appropriate apprehension or even fear, not social phobia. On the other hand, turning down a job that requires public speaking could be an indication of social phobia. Similarly, getting the jitters opening night in your first community theater production is normal fear. Avoiding the theater altogether, even if you love it, because you believe others may be critical, could be social phobia.

Sometimes, you may be able to force yourself to endure such events, but only after dreading them for weeks beforehand. During the event, or even for days leading up to it, you may have intense anxiety and a variety of physical reactions, such as sweating, blushing, tremors, diarrhea or stomach upset. Even the worry about having these signs and symptoms in public can heighten your anxiety and fear, which, in turn, worsens them — a vicious cycle.

Common, everyday experiences can be a source of social phobia:

• Using a public restroom or telephone
• Returning items to a store
• Interacting with strangers or with people of the opposite sex
• Writing in front of others
• Making eye contact
• Entering a room in which people are already seated
• Ordering food in a restaurant
• Being introduced to strangers

"These situations are extremely challenging for people with social phobia because they feel painfully self-conscious," Dr. Krahn explains. "They believe that others are watching them and expect them to harbor critical thoughts about them. They may feel that onlookers are critical of what they're doing, how they're doing it, what they're wearing and what they're saying to the point that they can't engage in a fairly simple activities — for example, talking to a clerk when people are lined up nearby waiting."

Some of the features that suggest true social phobia rather than normal shyness or reserve:

• An intense and persistent fear of social or performance situations in which you may not know people or may be judged
• Avoiding the social situations you fear
• Fear of being embarrassed or humiliated
• Fear that others will notice you blushing, sweating, trembling or showing other signs of anxiety
• The avoidance or distress interferes with your life
• Recognizing that your fear is excessive or unreasonable for the situation

There are two types of social phobia. In global social phobia, you have trouble with virtually all social situations. In specific social phobia, you have trouble only with a few situations. Together, both types affect about 4 percent of U.S. adults, or slightly more than 5 million people.

In either case, social phobia can be debilitating. It can prevent you from making friends and limit your career or educational opportunities. It can be a risk factor for other health problems, such as substance abuse or excessive drinking in an attempt to cope. And it can also lead to depression or suicide.

Social phobia tends to begin in childhood or early adolescence. Although it typically persists for life, often waxing and waning, treatment can help you control it. The two most effective types of treatment are psychotherapy and medications, often in combination.

Therapy is often a form called cognitive behavioral therapy. It's based on the premise that your own thoughts — not other people or situations — determine how you behave or react. Even if an unwanted situation hasn't changed — you still have to give that presentation to management, for instance — you can change the way you think and behave in a positive way.

Therapy may also include exposure therapy, in which you face the situations you fear most and gradually become better skilled in coping with them. And you may also participate in skills training or role playing to practice your social skills and gain comfort relating to others.

Numerous types of medications may help social phobia, since the condition may be associated with a chemical imbalance in the brain. The Food and Drug Administration, however, has specifically approved only three medications to treat social phobia:

• Paroxetine. Paroxetine (Paxil, Paxil CR) is a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). SSRIs help balance out a brain chemical called serotonin, which can help relieve symptoms of social phobia. Side effects may include nausea, diarrhea, decreased appetite, sweating, abnormal vision and sexual problems.

• Sertraline. Sertraline (Zoloft) is also an SSRI. Its most common side effects include upset stomach, sleeping difficulties, diarrhea, dry mouth, sexual problems, feeling sleepy or tired, tremor, sweating, agitation and decreased appetite.

• Venlafaxine. Venlafaxine (Effexor) is a type of antidepressant called a serotonin and norepinephrine reuptake inhibitor (SNRI). It helps to balance out both serotonin and another brain chemical, norepinephrine. Common side effects include nausea, dizziness, sleepiness, delayed ejaculation, sweating, dry mouth, insomnia, anorexia and constipation.

For some people, the symptoms of social phobia may fade over time, and medication can be discontinued. Others may have to take medication for years to prevent a relapse.

Which medication, if any, is best for you depends on your situation. Talk to your doctor about whether medications are right for you.

Although social phobia generally requires help from a medical expert or qualified psychotherapist, you can try some self-help techniques to cope with stressful situations. Among them:

• Imagine a stressful situation happening in a comfortable place.
• Eat with a close relative, friend or acquaintance in a public setting — a picnic or a restaurant.
• Make eye contact and return greetings from others, or say hello first.
• Prepare for conversation. For instance, read the newspaper to identify an interesting story you can talk about.
• Practice relaxation exercises.
• Give someone a compliment.
• Focus on personal qualities you like about yourself.
• Show an interest in others. Ask about their homes, children and grandchildren, hobbies or travels.
• Ask a retail clerk to help you find an item.
• Get directions from a stranger.

If your anxiety and physical reactions to social situations prevent you from leading the kind of life you want despite your self-help efforts, talk to your doctor. With treatment, you may find new opportunities opening up.

"Oftentimes, people with social phobia suffer in private — they don't tell anyone about their distress," Dr. Krahn says. "They can endure great pain and not get any help. But once they muster the courage to tell a doctor or mental health expert about their social ill-ease, it becomes possible to start treatment. And liberating yourself from what can be a prison of extreme shyness opens the door for a more fulfilling and rewarding life."

By Mayo Clinic staff

HQ00585

August 27, 2003

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